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neuro.sah-grade1-3.v1

Aneurysmal SAH — Good Grade (Hunt-Hess I–III)

neurologyacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Detailed

Good-grade aneurysmal SAH (HH I–III) — alert/drowsy patient with thunderclap + subarachnoid blood [AHA/ASA 2023 PMID 37212182]

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HH I–III stratum confirmed

Patient inputs (11)

Age + comorbidity shape coil vs clip decision; older patients trend toward coiling [AHA/ASA 2023; ISAT 2005]

Confirms SAH + modified Fisher grade (vasospasm risk) [Fisher 1980; AHA/ASA 2023]

Identifies aneurysm + location (AComm/PComm/MCA/basilar tip/vertebral-PICA); drives coil-vs-clip ladder [AHA/ASA 2023; ISAT 2005]

q6–8h Na for SIADH vs CSWS [NCS 2023 PMID 37202712]

GCS confirms HH I–III stratum (good grade); GCS drop redirects to HH IV–V engine [Hunt-Hess 1968]

HH I–III drives early-securing-within-24h pathway; HH I/II low DCI risk, HH III higher DCI risk + cEEG threshold [Hunt-Hess 1968; AHA/ASA 2023]

2023 AHA/ASA Class IIa — SBP <160 pre-secure with nicardipine first-line [Hoh Stroke 2023]

Reverse before aneurysm securing [AHA/ASA 2023]

DSA gold standard for aneurysm anatomy when CTA equivocal [AHA/ASA 2023]

Pregnancy alters securing strategy + delivery planning [AHA/ASA 2023]

Family aneurysm screening indication if ≥2 first-degree relatives OR ADPKD [AHA/ASA 2023]

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (11)

11 need judgement
  • informationallife_threateningbasilar_tip_aneurysm
    Basilar tip / posterior circulation aneurysm — coiling clearly favoured by ISAT due to surgical access difficulty; basilar perforator injury risk
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereHH_III_drowsy_mild_focal
    HH III — drowsiness / confusion OR mild focal neurologic deficit; mortality ~10–15% [Hunt-Hess 1968]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereACommA_aneurysm_predominant
    Anterior communicating artery aneurysm — most common (~30%); risk frontal-lobe edema, hypothalamic injury → DI/SIADH, post-securing cognitive/behavioural changes
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverePComm_aneurysm
    Posterior communicating artery aneurysm — CN III palsy (pupil-involving "down-and-out") is sentinel sign
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereMCA_bifurcation
    MCA bifurcation aneurysm — wide-necked with M2 branch involvement common; treatment decision individualised (neither coil nor clip clearly superior — BRAT 2012)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverevertebral_PICA
    Vertebral artery / PICA aneurysm — often dissecting; medullary territory infarct risk → lower-CN dysfunction affecting swallow and airway
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecoiling_vs_clipping
    Treatment-modality decision — coiling preferred posterior circulation (ISAT); individualised anterior; clipping for wide-neck MCA OR parenchymal hematoma evacuation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_aneurysmal_SAH
    Pregnancy + good-grade aSAH — securing strategy individualised by trimester; coiling generally preferred to minimise radiation/anesthesia complexity
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateHH_I_asymp_minimal_HA
    HH I — asymptomatic or minimal headache; GCS 15; no focal deficit; mortality ~0–2% [Hunt-Hess 1968]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateHH_II_mod_HA_no_focal
    HH II — moderate-to-severe headache, nuchal rigidity, no focal deficit except CN palsy (often CN III or VI); mortality ~2–5% [Hunt-Hess 1968]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildfamily_history_screening_indication
    Family history aneurysm/SAH (≥2 first-degree relatives) OR ADPKD — screening MRA offered
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

Good-grade aSAH (HH I–III) — early securing ≤24 h + nimodipine + BP <160 pre-secure + DCI rescue (AHA/ASA 2023 + NCS 2023)
axis: sah_good_grade_acute_bundlestep 1 - Step 1 — Nimodipine for DCI prevention (Day 0)
Selected step "Step 1 — Nimodipine for DCI prevention (Day 0)" — Confirmed aSAH HH I–III; start within 96 h of bleed
  • nimodipine
    first line
    CCB_dihydropyridine
    60 mg PO/NG q4h × 21 days • PO • q4h (max: 60 mg q4h)
    triggers: confirmed_aSAH_HH_I_to_III
    BRANT (Pickard BMJ 1989 PMID 2496789) — Class I per 2023 AHA/ASA; reduces poor outcome from DCI. NEVER IV (FDA boxed warning — fatal hypotension).
    rxcui 7426

outpatient playbook — drug actions (4)

  1. 1. ACEI/ARB + thiazide
    Lisinopril 10–40 mg PO daily; chlorthalidone 12.5–25 mg PO daily • PO • daily
    trigger: BP ≥130/80
    2025 AHA/ACC HTN — target <130/80 to reduce recurrent SAH + de-novo aneurysm formation
  2. 2. atorvastatin
    40–80 mg PO daily per ASCVD risk • PO • once daily
    trigger: ASCVD 10-y risk ≥7.5% OR known atherosclerosis
    2026 ACC/AHA Lipid — primary/secondary prevention per risk (chronic statin per ASCVD risk independent of STASH negative DCI data)
  3. 3. varenicline OR NRT OR bupropion
    Varenicline 0.5 mg PO daily × 3 d → 0.5 BID × 4 d → 1 mg BID × 11 wk • PO/patch/lozenge • per agent
    trigger: Active tobacco use
    AHA/ASA 2023 Class I — smoking strongest modifiable risk
  4. 4. donepezil (if cognitive impairment)
    5–10 mg PO daily • PO • daily
    trigger: MoCA <26 with functional impact
    Off-label individualised consideration (AHA/ASA 2023)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Thunderclap headache, GCS 15, no/minimal focal deficit (HH I–II) [AHA/ASA 2023 Hoh PMID 37212182]; Drowsiness OR mild focal deficit (HH III) with thunderclap [Hunt-Hess 1968; AHA/ASA 2023]; CT showing subarachnoid blood in alert patient (Fisher I–IV) [AHA/ASA 2023].

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Aneurysmal SAH — Good Grade (Hunt-Hess I–III)** (neuro.sah-grade1-3.v1).
Phenotype framing: Aneurysmal vs perimesencephalic (route to neuro.sah-perimesencephalic.v1) vs AVM vs RCVS vs dissection [AHA/ASA 2023]
Scope: Good-grade aneurysmal SAH (HH I–III) — alert/drowsy patient with thunderclap + subarachnoid blood [AHA/ASA 2023 PMID 37212182]

No severity triggers fired against current inputs.

Plan

Regimen axis: **Good-grade aSAH (HH I–III) — early securing ≤24 h + nimodipine + BP <160 pre-secure + DCI rescue (AHA/ASA 2023 + NCS 2023)** — step "Step 1 — Nimodipine for DCI prevention (Day 0)".
1. nimodipine 60 mg PO/NG q4h × 21 days PO q4h (CCB_dihydropyridine, first line) — BRANT (Pickard BMJ 1989 PMID 2496789) — Class I per 2023 AHA/ASA; reduces poor outcome from DCI. NEVER IV (FDA boxed warning — fatal hypotension).

Setting playbook (outpatient) — Cerebrovascular clinic 6 wk / 3 / 6 / 12 mo; BP <130/80; smoking cessation; family aneurysm screen; cognitive rehab; repeat MRA 6 mo; return-to-work plan tiered by HH at admission [AHA/ASA 2023]
2. ACEI/ARB + thiazide Lisinopril 10–40 mg PO daily; chlorthalidone 12.5–25 mg PO daily PO daily — BP ≥130/80 (2025 AHA/ACC HTN — target <130/80 to reduce recurrent SAH + de-novo aneurysm formation)
3. atorvastatin 40–80 mg PO daily per ASCVD risk PO once daily — ASCVD 10-y risk ≥7.5% OR known atherosclerosis (2026 ACC/AHA Lipid — primary/secondary prevention per risk (chronic statin per ASCVD risk independent of STASH negative DCI data))
4. varenicline OR NRT OR bupropion Varenicline 0.5 mg PO daily × 3 d → 0.5 BID × 4 d → 1 mg BID × 11 wk PO/patch/lozenge per agent — Active tobacco use (AHA/ASA 2023 Class I — smoking strongest modifiable risk)
5. donepezil (if cognitive impairment) 5–10 mg PO daily PO daily — MoCA <26 with functional impact (Off-label individualised consideration (AHA/ASA 2023))

Non-pharmacologic actions:
- Cerebrovascular clinic 6 wk / 3 / 6 / 12 mo (AHA/ASA 2023)
- Family aneurysm MRA screening offered if ≥2 first-degree relatives OR ADPKD (AHA/ASA 2023)
- Neuropsychological testing at 3 mo (AHA/ASA 2023)
- Return-to-work tiered by HH at admission (HH I–II ~3 mo; HH III 6–12 mo)
- Driving evaluation per jurisdiction (3–6 mo abstention) (AHA/ASA 2023)
- Aerobic exercise 150 min/wk moderate intensity once cleared (AHA/ASA 2023)
- Annual influenza + pneumococcal + COVID per ACIP 2026

AVOID / contraindication checks:
- No_routine_seizure_prophylaxis (AHA/ASA 2023)
- Abandon_triple H_use_euvolemic_induced_HTN (HIMALAIA 2014 PMID 29158449)
- Avoid_SBP_<90_on_nimodipine (AHA/ASA 2023)
- AVOID_long_course_antifibrinolytic (ULTRA 2021 PMID 33357465)
- Nimodipine_PO_NG_only_NEVER_IV (FDA boxed warning)
- Coil_preferred_posterior_circulation (ISAT 2005 PMID 16139655)

Monitoring

Regimen monitoring:
- TCD daily days 3-14 for vasospasm (AHA/ASA 2023)
- q1-2h neuro checks (AHA/ASA 2023)
- CT perfusion if clinical decline (AHA/ASA 2023)
- serum Na q6-8h for SIADH vs CSWS (NCS 2023)
- GCS continuous (AHA/ASA 2023)
- continuous arterial BP (AHA/ASA 2023)
- cEEG if HH III with persistent AMS (NCS 2023)

Setting (outpatient) monitoring:
- BP home log + clinic q3 mo until at goal then q6 mo (2025 AHA/ACC HTN)
- Lipid panel at 4–6 wk after statin start; then q6–12 mo (2026 ACC/AHA Lipid)
- MRA at 6 mo (AHA/ASA 2023)
- mRS at 90 d / 6 mo / 12 mo (AHA/ASA 2023)
- MoCA + PHQ-9 at 3 / 6 / 12 mo (AHA/ASA 2023)

Follow-up plan: Cerebrovascular clinic 6 wk / 3 / 6 / 12 mo; BP <130/80 (2025 AHA/ACC HTN); smoking cessation; family aneurysm screening if ≥2 first-degree relatives or ADPKD; rehab; cognitive eval (MoCA + PHQ-9); repeat MRA at 6 mo [AHA/ASA 2023]
- Close-out criterion: Long-term plan set

Monitoring phase: Daily TCD days 3–14 (vasospasm screen) [AHA/ASA 2023]; q1–2 h neuro checks; CT perfusion if clinical decline; q6–8 h Na [NCS 2023]; cEEG if HH III with persistent AMS [NCS 2023]; DCI rescue → euvolemic induced HTN with norepi (target MAP 100–110); IA verapamil for refractory [AHA/ASA 2023; NCS 2023]

Disposition

Current setting: outpatient — Cerebrovascular clinic 6 wk / 3 / 6 / 12 mo; BP <130/80; smoking cessation; family aneurysm screen; cognitive rehab; repeat MRA 6 mo; return-to-work plan tiered by HH at admission [AHA/ASA 2023]

Disposition criteria:
- Indefinite cerebrovascular clinic; transition to PCP after stable year if no residual aneurysm (AHA/ASA 2023)

Escalation triggers (move to higher acuity):
- Any thunderclap → ED for re-rupture / new aneurysm (AHA/ASA 2023)
- New focal deficit → STAT CT/CTA for de-novo aneurysm/AVM (AHA/ASA 2023)
- PHQ-9 ≥15 or suicidal ideation → urgent psych (AHA/ASA 2023)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Basilar tip / posterior circulation aneurysm — coiling clearly favoured by ISAT due to surgical access difficulty; basilar perforator injury risk
- [SEVERE] HH III — drowsiness / confusion OR mild focal neurologic deficit; mortality ~10–15% [Hunt-Hess 1968]
- [SEVERE] Anterior communicating artery aneurysm — most common (~30%); risk frontal-lobe edema, hypothalamic injury → DI/SIADH, post-securing cognitive/behavioural changes

Citations

- 2023 AHA/ASA aSAH Guideline (Hoh et al, Stroke 2023 PMID 37212182) + 2023 NCS aSAH Management (Treggiari et al, Neurocrit Care 2023 PMID 37202712) [PMID:37212182](https://pubmed.ncbi.nlm.nih.gov/37212182/)
- Cited evidence (PMID 37202712) [PMID:37202712](https://pubmed.ncbi.nlm.nih.gov/37202712/)
- Cited evidence (PMID 33357465) [PMID:33357465](https://pubmed.ncbi.nlm.nih.gov/33357465/)
- Cited evidence (PMID 2496789) [PMID:2496789](https://pubmed.ncbi.nlm.nih.gov/2496789/)
- Cited evidence (PMID 16139655) [PMID:16139655](https://pubmed.ncbi.nlm.nih.gov/16139655/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 2023 AHA/ASA aSAH Guideline (Hoh et al, Stroke 2023 PMID 37212182) + 2023 NCS aSAH Management (Treggiari et al, Neurocrit Care 2023 PMID 37202712) — PMID:37212182
  • Cited evidence (PMID 37202712) — PMID:37202712
  • Cited evidence (PMID 33357465) — PMID:33357465
  • Cited evidence (PMID 2496789) — PMID:2496789
  • Cited evidence (PMID 16139655) — PMID:16139655